Daniel E. Holloway
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Emory LTAC complaint alleges premature decannulation and a failed reinsertion before a patient’s death

The complaint alleges that a 42-year-old stroke patient was transferred to Emory Long Term Acute Care on June 6, 2022, for ventilator weaning. He never passed a speaking-valve trial, and swallowing studies showed trauma and tissue growth on his vocal cords. On July 18, 2022, a pulmonologist ordered his tracheostomy tube removed, and a respiratory therapist documented the decannulation as uncomplicated. A patient care technician gave him a meal tray with meat despite an order for pureed food only. Later that afternoon he developed stridor, and the pulmonologist could not reinsert the tube because the stoma had closed. He was moved to intensive care, intubated, and vomited, dislodging the airway tube. The filing alleges that his death that day resulted from the defendants’ combined negligence.

System
Emory Healthcare
Facility
Emory Long Term Acute Care
Providers involved
Emory Healthcare, Inc / Decatur Healthcare, Inc. / Northside Hospital, Inc / Emory Specialty Associates, LLC / Terri Lynn TenHoor, M.D. / Southeastern Lung Care, P.C. / Mary K. Clark, PA / Trang Lai, RT / Deborah Saepharn, D.O. / Christie Cavorsi-Barber, SLP / Violet Davies, RN / Janet Davies, PCT / US Physiatry, LLC / US Physiatry of Georgia, LLC / Kyle Aman, MD
Pattern
Alleged decannulation of a tracheostomy despite failed valve trials and vocal-cord trauma
Harm
Alleged respiratory failure, cardiac arrest, and death after decannulation

Overview

This page concerns a public complaint alleging that hospital staff removed a patient’s tracheostomy tube despite failed speaking-valve trials and could not reinsert it.

Chronology

The complaint alleges as follows:

  1. The patient was transferred to Emory Long Term Acute Care on June 6, 2022, at age 42, for ventilator weaning after a stroke.
  2. Over the following weeks he repeatedly failed speaking-valve trials. Swallowing studies showed vocal-cord trauma, tissue growth, and left pharyngeal weakness.
  3. On July 16, 2022, a physician assistant charted that he was not a candidate for decannulation because of his cognitive status and airway secretions.
  4. On July 18, 2022, a pulmonologist ordered his tracheostomy tube removed, and a respiratory therapist documented the decannulation as uncomplicated.
  5. A patient care technician gave him a meal tray containing meat despite an order for pureed food only.
  6. Later that afternoon he developed stridor and respiratory distress, and the pulmonologist could not reinsert the tube because the stoma had closed.
  7. He was moved to intensive care, intubated, vomited, and lost the airway tube, and died after a resuscitation attempt on July 18, 2022.

Alleged failures

The complaint alleges the following failures:

  • The physicians and the physician assistant decannulated the patient although he had never passed a valve trial and his vocal cords showed trauma.
  • The nurse, respiratory therapist, and speech-language pathologist did not adequately monitor him after his stridor began.
  • The patient care technician gave him a meal tray with meat despite his order for pureed food only.
  • The filing alleges that his death resulted from the combined negligence of the defendants.
  • The complaint pleads medical malpractice, nursing negligence, ordinary negligence, and wrongful death, and attaches an expert affidavit under O.C.G.A. § 9-11-9.1.

Entities and tags

Emory Long Term Acute CareEmory Healthcare, IncDecatur Healthcare, Inc.Northside Hospital, IncTracheostomyDecannulationStridorDeKalb CountyAnesthesia and airwayFailure to monitorWrongful deathPulmonologyRespiratory therapySpeech-language pathologyCritical care